Regular Session 2021-2022 House Bill 0947 P.N. 1841

PRIOR PRINTER'S NO. 955

PRINTER'S NO. 1841

THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

No.

947

Session of

2021

INTRODUCED BY ZIMMERMAN, MILLARD, JAMES, JOZWIAK, GLEIM, MOUL,

DRISCOLL, KEEFER, R. BROWN, FREEMAN, BURGOS, RADER, GAYDOS,

JONES, IRVIN, SCHLEGEL CULVER AND WHEELAND, MARCH 17, 2021

AS REPORTED FROM COMMITTEE ON INSURANCE, HOUSE OF

REPRESENTATIVES, AS AMENDED, JUNE 16, 2021

AN ACT

Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

act relating to insurance; amending, revising, and

consolidating the law providing for the incorporation of

insurance companies, and the regulation, supervision, and

protection of home and foreign insurance companies, Lloyds

associations, reciprocal and inter-insurance exchanges, and

fire insurance rating bureaus, and the regulation and

supervision of insurance carried by such companies,

associations, and exchanges, including insurance carried by

the State Workmen's Insurance Fund; providing penalties; and

repealing existing laws," in casualty insurance, providing

for furnishing claims experience to policyholders.

AMENDING TITLE 40 (INSURANCE) OF THE PENNSYLVANIA CONSOLIDATED

STATUTES, IN REGULATION OF INSURERS AND RELATED PERSONS

GENERALLY, PROVIDING FOR GROUP MARKET PROVISIONS.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1. The act of May 17, 1921 (P.L.682, No.284), known

as The Insurance Company Law of 1921, is amended by adding a

section to read:

Section 621.6. Furnishing Claims Experience to

Policyholders.--(a) Subject to the other provisions of this

section, each insurer shall furnish, regardless of the rating

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methodology used, claims experience to group policyholders

within thirty days of a policyholder's request unless the

information has been furnished to the group policyholder within

the preceding six months.

(b) Claims experience shall be furnished for all groups of

fifty-one or more covered employes, members or enrollees, not

including dependents.

(1) Earned premiums separated by policy year for at least

the last two policy years, if applicable.

(2) Total paid claims and total incurred claims, inclusive

of any high amount or pooled claims, including both capitated

and noncapitated expenses specified in the same manner as

premiums.

(3) Any amounts in excess of the individual pooling or stop-

loss point applicable to the group.

(d) An insurer that utilizes provider contracting methods,

including financial devices such as global fee arrangements, to

cover all medical expenses may apply to the commissioner for

approval of the use of an alternative form of claims experience

reporting. The following shall apply:

(1) The insurer shall provide Commonwealth experience on a

group-specific basis or on another reasonable basis as the

commissioner may approve for the insurer, in advance, based upon

a submission of an explanation and supporting documentation.

(2) An insurer that received approval for an alternative

form of group claims experience reporting to policyholders shall

be required to seek the commissioner's advance approval of a

proposed response letter to group policyholders who request

experience reporting. The letter shall describe the insurer's

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reasons for seeking an alternative reporting process and

describe the alternative form of reporting approved by the

commissioner.

(e) An insurer may charge a reasonable fee for providing the

information under this section to group policyholders. The

schedule or amount of fees to be charged to group policyholders

for providing the information shall be filed by each insurer

with the commissioner.

(f) In providing claims experience to group policyholders

under this section, an insurer shall adhere to all Federal and

State laws regarding disclosure of protected health or personal

information.

(g) As used in this section:

"Commissioner" means the Insurance Commissioner of the

Commonwealth.

"Insurer" means an entity licensed by the Insurance

Department with accident and health authority to issue a policy,

subscriber contract, certificate or plan that provides medical

or health care coverage, including emergency services, and is

offered or governed under any of the following:

(1) This act, including section 630 and Article XXIV.

(2) The act of December 29, 1972 (P.L.1701, No.364), known

as the "Health Maintenance Organization Act."

(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan

corporations) or 63 (relating to professional health services

plan corporations).

SECTION 1. TITLE 40 OF THE PENNSYLVANIA CONSOLIDATED

STATUTES IS AMENDED BY ADDING A CHAPTER TO READ:

CHAPTER 41

GROUP MARKET PROVISIONS

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SUBCHAPTER

A. PRELIMINARY PROVISIONS

B. PROCEDURES

C. MISCELLANEOUS PROVISIONS

SUBCHAPTER A

PRELIMINARY PROVISIONS

SEC.

4101. DEFINITIONS.

§ 4101. DEFINITIONS.

THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS CHAPTER

SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE

CONTEXT CLEARLY INDICATES OTHERWISE:

"COMMISSIONER." THE INSURANCE COMMISSIONER OF THE

COMMONWEALTH.

"DEPARTMENT." THE INSURANCE DEPARTMENT OF THE COMMONWEALTH.

"INSURER." AN ENTITY LICENSED BY THE DEPARTMENT WITH

ACCIDENT AND HEALTH AUTHORITY TO ISSUE A POLICY, SUBSCRIBER

CONTRACT, CERTIFICATE OR PLAN THAT PROVIDES MEDICAL OR HEALTH

CARE COVERAGE, INCLUDING EMERGENCY SERVICES, AND IS OFFERED OR

GOVERNED UNDER ANY OF THE FOLLOWING:

(1) THE ACT OF MAY 17, 1921 (P.L.682, NO.284), KNOWN AS

THE INSURANCE COMPANY LAW OF 1921, INCLUDING SECTION 630 AND

ARTICLE XXIV THEREOF.

(2) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364),

KNOWN AS THE HEALTH MAINTENANCE ORGANIZATION ACT.

(3) CHAPTER 61 (RELATING TO HOSPITAL PLAN CORPORATIONS)

OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES PLAN

CORPORATIONS).

SUBCHAPTER B

PROCEDURES

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SEC.

4111. FURNISHING CLAIMS EXPERIENCE DATA TO POLICYHOLDERS.

§ 4111. FURNISHING CLAIMS EXPERIENCE DATA TO POLICYHOLDERS.

(A) GENERAL RULE.--SUBJECT TO THE OTHER PROVISIONS OF THIS

CHAPTER, EACH INSURER SHALL FURNISH CLAIMS EXPERIENCE DATA TO

GROUP POLICYHOLDERS WITHIN 30 DAYS OF A GROUP POLICYHOLDER'S

REQUEST UNLESS THE INFORMATION HAS BEEN FURNISHED TO THE GROUP

POLICYHOLDER WITHIN THE PRECEDING SIX MONTHS.

(B) APPLICABLE GROUP SIZE.--CLAIMS EXPERIENCE DATA SHALL BE

FURNISHED FOR EACH GROUP OF 51 OR MORE COVERED EMPLOYES, MEMBERS

OR ENROLLEES, NOT INCLUDING DEPENDENTS.

CHAPTER, CLAIMS EXPERIENCE DATA INCLUDES, FOR AT LEAST THE LAST

TWO POLICY YEARS, IF APPLICABLE, SEPARATED BY POLICY YEAR, THE

AGGREGATED DOLLAR VALUE OF EACH OF THE FOLLOWING:

(1) EARNED PREMIUMS.

(2) TOTAL INCURRED CLAIMS, INCLUDING PAID, RESERVED AND

INCURRED BUT NOT RESERVED CLAIMS, INCLUSIVE OF HIGH AMOUNT

CLAIMS, POOLED CLAIMS, CAPITATED EXPENSES AND NONCAPITATED

EXPENSES.

(3) ANY AMOUNTS INCURRED IN EXCESS OF THE INDIVIDUAL

POOLING OR STOP-LOSS POINT APPLICABLE TO THE GROUP.

(4) ANY AMOUNTS UNDER A PROVIDER REIMBURSEMENT

METHODOLOGY OTHER THAN FEE FOR SERVICE THAT WERE ALLOCATED TO

THE GROUP OR OTHERWISE ACCOUNTED FOR IN RATING THE GROUP'S

POLICY.

(D) FEE PERMITTED.--AN INSURER MAY CHARGE A FEE FOR

PROVIDING THE CLAIMS EXPERIENCE DATA TO A GROUP POLICYHOLDER.

THE FEE SHALL BE:

(1) REASONABLE.

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(2) NOT UNFAIRLY DISCRIMINATORY.

(3) IN ACCORD WITH A SCHEDULE OR METHODOLOGY FILED WITH

THE DEPARTMENT AT LEAST 30 DAYS PRIOR TO USE, WHICH SCHEDULE

SHALL BECOME EFFECTIVE UNLESS DISAPPROVED BY THE DEPARTMENT

PRIOR TO USE.

(E) PRIVACY PROTECTION.--IN PROVIDING CLAIMS EXPERIENCE DATA

TO A GROUP POLICYHOLDER UNDER THIS CHAPTER, AN INSURER SHALL

ADHERE TO ALL FEDERAL AND STATE LAWS REGARDING DISCLOSURE OF

PROTECTED HEALTH OR PERSONAL INFORMATION.

SUBCHAPTER C

MISCELLANEOUS PROVISIONS

SEC.

4121. REGULATIONS.

4122. ENFORCEMENT AND PENALTIES.

§ 4121. REGULATIONS.

THE DEPARTMENT MAY PROMULGATE REGULATIONS AS NECESSARY AND

APPROPRIATE TO IMPLEMENT THIS CHAPTER.

§ 4122. ENFORCEMENT AND PENALTIES.

(A) GENERAL RULE.--SUBJECT TO THE OTHER PROVISIONS OF THIS

SECTION, UPON SATISFACTORY EVIDENCE OF THE VIOLATION OF ANY

SECTION OF THIS CHAPTER BY AN INSURER OR ANY OTHER PERSON, ONE

OR MORE OF THE FOLLOWING PENALTIES MAY BE IMPOSED AT THE

COMMISSIONER'S DISCRETION:

(1) SUSPENSION OR REVOCATION OF THE LICENSE OF THE

OFFENDING INSURER OR OTHER PERSON.

(2) REFUSAL, FOR A PERIOD NOT TO EXCEED ONE YEAR, TO

ISSUE A NEW LICENSE TO THE OFFENDING INSURER OR OTHER PERSON.

(3) A FINE OF NOT MORE THAN $5,000 FOR EACH VIOLATION OF

THIS CHAPTER.

(4) A FINE OF NOT MORE THAN $10,000 FOR EACH WILLFUL

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VIOLATION OF THIS CHAPTER.

(B) LIMITATIONS.--

(1) FINES IMPOSED UNDER THIS SECTION AGAINST AN INSURER

MAY NOT EXCEED $500,000 IN THE AGGREGATE DURING A SINGLE

CALENDAR YEAR.

(2) FINES IMPOSED UNDER THIS SECTION AGAINST ANY OTHER

PERSON MAY NOT EXCEED $100,000 IN THE AGGREGATE DURING A

SINGLE CALENDAR YEAR.

UNDER THIS SECTION ARE IN ADDITION TO OTHER REMEDIES OR

PENALTIES THAT MAY BE IMPOSED UNDER OTHER APPLICABLE LAW OF THIS

COMMONWEALTH, INCLUDING:

(1) THE ACT OF DECEMBER 18, 1996 (P.L.1066, NO.159),

KNOWN AS THE ACCIDENT AND HEALTH FILING REFORM ACT.

(2) THE ACT OF JULY 22, 1974 (P.L.589, NO.205), KNOWN AS

THE UNFAIR INSURANCE PRACTICES ACT. VIOLATIONS OF THIS

CHAPTER SHALL BE DEEMED TO BE UNFAIR METHODS OF COMPETITION

AND UNFAIR OR DECEPTIVE ACTS OR PRACTICES UNDER THE UNFAIR

INSURANCE PRACTICES ACT.

(3) THE ACT OF JUNE 25, 1997 (P.L.295, NO.29), KNOWN AS

THE PENNSYLVANIA HEALTH CARE INSURANCE PORTABILITY ACT.

(D) ADMINISTRATIVE PROCEDURE.--

(1) THE ADMINISTRATIVE PROVISIONS OF THIS SECTION SHALL

BE SUBJECT TO 2 PA.C.S. CH. 5 SUBCH. A (RELATING TO PRACTICE

AND PROCEDURE OF COMMONWEALTH AGENCIES).

(2) A PARTY AGAINST WHOM PENALTIES ARE ASSESSED IN AN

ADMINISTRATIVE ACTION MAY APPEAL TO COMMONWEALTH COURT AS

PROVIDED IN 2 PA.C.S. CH. 7 SUBCH. A (RELATING TO JUDICIAL

REVIEW OF COMMONWEALTH AGENCY ACTION).

Section 2. This act shall take effect in 60 days.

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